Looking ForwardA AMA P tiAn AMA Perspective

Alliance of Independent AcademicAlliance of Independent Academic Medical Centers Annual Meeting

March 26 2010March 26, 2010Paul Rockey, MD, MPH

Director Graduate Medical EducationDirector, Graduate Medical Education

Today’s Themes . . .

• AMA Strategic Issues• AMA Strategic Issues • AMA Advocacy Agenda • Physician Workforce and GME• International IssuesInternational Issues• 100 Year Shadow of Flexner

The DoctorThe DoctorThe DoctorThe DoctorBy Samuel Luke Fildes, 1891

AMA Strategic Issues

• Access• Access • Quality• Cost• Prevention and WellnessPrevention and Wellness• Payment Models

AMA Advocacy Agenda

• Voice for the uninsured• Funding research and medical

education, especially GME, p y• Expand Title VII and NHSC programs• Patient-centered medical homes and• Patient-centered medical homes and

accountable care organizations

www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy.shtml

AMA HSR Advocacy Agenda

• Medical liability reform• Medicare physician payment reform and

regulatory relief• Quality, affordable health care for all• Combat third-party interference with

physician-patient relationship• Medicare balance billing• Improving the health of the public• Patient safety and quality improvementPatient safety and quality improvement

FL3

Slide 6

FL3 Fred Lenhoff, 2/11/2010

Upcoming AMA Reports

Securing Funding for GME• Securing Funding for GME• Primary Care & Medical Home Model• Maintenance of Certification/

Maintenance of Licensure• Visa and Licensure Process for IMG

Residents• Employment Benefits for Residents

and Fellows

Physician Workforce and GME

• U S physicians per capita• U.S. physicians per capita• Physician workforce shortages• Demand vs. supply• GME funding issuesGME funding issues• COGME’s recommendations• MedPAC issues related to GME

U.S. Physicians per Capita

276 283300

MDs to 100,000

202

276 283

250

300

175

125140

202

150

200

50

100

0

50

1900 1930 1960 1980 2000 20101900 1930 1960 1980 2000 2010Year

States Reporting Physician Shortages

• Montana (2009)• New Jersey (2009)

• North Carolina (2007)• Virginia (2007)

• California (2008)• Georgia (2008)• Maryland (2008)

• Alaska (2006)• Michigan (2006)• New Mexico (2006)y ( )

• Massachusetts (2008)• Minnesota (2008)• Nebraska (2008)

• New Mexico (2006)• Nevada (2006)• Utah (2006)

• Nebraska (2008)• Pennsylvania (2008)• Colorado (2007)

( )

• Arizona (2005)• Florida (2005)• Oregon (2004)• Kentucky (2007)

• Idaho (2007)• Iowa (2007)

• Oregon (2004)• Wisconsin (2004)• Mississippi (2003)

• New York (regional) (2007) • Texas (2002)

Specialties Reporting Shortages

• Gastroenterology (2009)• Thoracic Surgery (2009)

• Child Psychiatry (2006) • Critical Care Workforce

• General Surgery (2008)• Generalist Physicians

(2008)

(2006)• Emergency Medicine

(2006)(2008)• Geriatric Medicine (2008)• Oncology (2007)

• Family Medicine (2006)• Neurosurgery (2005)

C di l (2004)• Pediatric Subspecialties (2007)

• Public Health (2007)

• Cardiology (2004)• Dermatology (2004)• Medical Genetics (2004)( )

• Rheumatology (2007)• Allergy and Immunology

(2006)

( )• Anesthesiology (2003)• Endocrinology (2003)

P hi t (2003)(2006) • Psychiatry (2003)

Drivers of Future Demand for U.S. Physicians

• Population growth: 25 million/decade• Population growth: 25 million/decade • Aging population: Over 65s will double

2000 2030 major illness/chronic illness2000-2030, major illness/chronic illness • Public expectations: Boomers have

more resources and higher expectationsmore resources and higher expectations • Lifestyle factors: e.g., obesity, diabetes • Economic growth of nation• Medical advances: cut both ways

Future Physician Supply

• Medical school (MD) enrollment doubled from• Medical school (MD) enrollment doubled from 1960 to 1980, then flat for 20+ years

• ~ 19 000 MDs & DOs graduate each year 19,000 MDs & DOs graduate each year• Aging of physician workforce and retirement

• Gender and generational differences• Gender and generational differences

• Residency positions key to future supply

• International migration and IMG policies

Projected Physician Shortage by 2025

900,000

Shortage by 2025

850,000

ns

Baseline demand

Shortage:124 400

750 000

800,000

E Ph

ysic

ian 124,400

700,000

750,000

FTE

Baseline supply

650,0002005 2010 2015 2020 2025

SOURCE: 2008 Association of American Medical Colleges.

USMD Graduates Over Six Decades

19500 19,296

15500

16500

17500

18500

19500

Enrollments

12500

13500

14500

15500

8500

9500

10500

11500Graduates

6500

7500

1954 1964 1974 1984 1994 2004 2012

The Number of Active Physicians Approaching R ti t A i I i Sh l

30,000

s

Retirement Age is Increasing Sharply

22 52623,902

20 000

25,000

Phys

icia

ns 25,000 Physicians Enter Training Each Year

Number of Physicians Reaching Age 63

22,526(2025)

(2017)

15,000

20,000

of A

ctiv

e P

13,708(2008)10,000

Num

ber

5,0002008 2010 2012 2014 2016 2018 2020 2022 2024

Source: AMA Physician Masterfile (January 2008)Source: AMA Physician Masterfile (January 2008)

One Out of Three Would Retire Today if They Could Afford to

Percent of active physicians over 50 who would retire today, by age

42% 41%

33%40%

50%

33%

21%16%

32%

20%

30%

16%12%

10%

20%

0%50-54 55-59 60-64 65-69 70-74 75+ Total

Age CategoryAge Category

Source: 2006 AAMC/AMA Survey of Physicians 50 and Over

Percentage of Women in Medicine i Ri i St dilis Rising Steadily

42% 44% 45% 46% 47%40%45%50%

e

Medical School Graduates

29%34%

39%

27% 28% 29%25%30%35%

t F

em

ale

23%

13%15%

20%23% 24%

27% 28%

10%15%20%

Pe

rce

nt

Practicing MDs

10%13%

0%5%

10%

1980 1985 1990 1995 2000 2002 2003 2004 20051980 1985 1990 1995 2000 2002 2003 2004 2005

Fixing U.S. Doctor Shortage Requires More GME Slots

I 1997 M di l d f d d GME• In 1997, Medicare placed caps on funded GME positions (~26,000 GY1s per year)

• GME: only path to U S Physician licensureGME: only path to U.S. Physician licensure • ~ 19,000 MDs and DOs graduate each year• Increasing class sizes, 12 new MD schoolsIncreasing class sizes, 12 new MD schools• 30% increase = 5,700 more U.S. graduates • Unless GME expands, U.S. MDs and DOs will U ess G e pa ds, U S s a d Os

compete with IMGs for the same slots

GME Funding Sources

• Medicare supports 40% of total costMedicare supports 40% of total cost• Medicaid (annual state appropriations

and matching federal payments)and matching federal payments)• Veterans Administration (10% of

residents)residents)• Department of Defense

P i t (b t hifti )• Private payers (by cost shifting)

Council on Graduate Medical Education Recommendations

• Move more physician training to non-Move more physician training to non-hospital settings, including rural and underserved areas

• Make teaching hospitals/academic medical centers more accountable for CMS funding

• Fix the income disparity between p yprimary care and specialist physicians

• Make GME a site for innovations in primary care

Other GME Funding Issues

• Need to expand GME positions to keep up with medical school expansion

• Need for innovative training models to address community needs and contemporary models of health care (medical home/chronic care models)(medical home/chronic care models)

• New and emerging DME costs (technology resident duty hour(technology, resident duty hour restrictions, etc.)

MedPAC Issues Related to GME

• Increasing accountabilityg y• Broadening training settings• Creating career incentives for• Creating career incentives for

residents• Alternative financing models• Alternative financing models• Economic incentives (team-based

care faculty expertise costcare, faculty expertise, cost awareness, cultural competencies, community-based affiliations)y )

International Issues• IMGs – why the concern now?

S it I t ti l A ti iti• Summit on International Activities• International Accreditation of Medical

Ed tiEducation• International Medical Workforce

C ll b ti (IMWC)Collaborative (IMWC)• World Health Professions’ Conference

R l ti (WHPCR)on Regulation (WHPCR)• A local angle

IMGs – Why the concern now?

• IMGs account for 25.9% of total physiciansy• Global shortages of health personnel• Brain drain from less-developed countries • 1 of 4 doctors in GME is non-U.S. IMG • About 2,500 U.S. citizens per year enter

foreign med schools, mostly Caribbean• 1,500 U.S. IMGs enter U.S. GME annually

V i bili i li f f i d h l• Variability in quality of foreign med schools and IMG graduates

U.S. IMGs Certified by ECFMG Continues to IncreaseVast Majority (80%) are from the Caribbean

2 500

3,000

j y ( )

2,302

2,000

2,500

Total US IMGs1,847

1,000

1,500

US C ibb G d t

0

500US Caribbean Graduates

1996 1998 2000 2002 2004 2006 2008*

*2008 numbers are projections through 12/31/07 based on certifications as of 10/13/07.Source: ECFMG

Variability of Medical Education by Caribbean Medical Schools

• 55 medical schools in Caribbean55 medical schools in Caribbean• Tuition funded – U.S. DOE student loans• No teaching hospitals – buy U.S. clerkshipsNo teaching hospitals buy U.S. clerkships• Lower pass rates on first-attempt of USMLE• Compete with U.S. graduates and non-U.S. p g

citizen IMGs for U.S. residency positions • U.S. citizen IMG entry to residency enhanced

b E li h fi i U S li i l t i iby English proficiency, U.S. clinical training, no visa requirements

ECFMG Summit on International Activities

I t ti l di l h l t d d• International medical school standards • International GME standards• Accreditation of medical schools and

residency training programs• Licensing and MOL• Certification and MOC• Accreditation of hospitals

International Accreditation of Medical Education

• Undergraduate medical education (Cornell: Qatar; Duke: Singapore)

• UME Accreditation (WFME, FAIMER)• GME (ACGME and Singapore)• Teaching hospitals (Joint Commission)• Specialty medicine (ABMS)Specialty medicine (ABMS)

International Medical Workforce Collaborative

• Team based models of primary medical care and• Team-based models of primary medical care and complex care management (Australia)

• Social mission of medical schools in time of expansion (US)

• Optimizing medical workforce through improved t ffi i & h i i t i i (C d )system efficiency & physician training (Canada)

• Reducing physician requirements by improving practice and organizational efficiency (UK)practice and organizational efficiency (UK)

www.rcpsc.medical.org/publicpolicy/imwc.php/p g p p y p p

World Health Professions’ Conference on Regulation

E l d i d f t f h lth• Explore a desired future for health professional regulation

• Examine regulatory and professional• Examine regulatory and professional issues related to international migration of health professionals

• Evaluate the relationships among health professional education,

l ti d t d d f tiregulation, and standards of practice

www whpa org/whpcr2010/www.whpa.org/whpcr2010/

Ochsner – University of Queensland School of Medicine Collaboration

• New medical school program for U S citizens• New medical school program for U.S. citizens• 2 years of pre-clinical education at University of

Queensland in Australia • 2 years of clinical instruction at Ochsner in

Louisiana

• Emphasis on primary care in the curriculumEmphasis on primary care in the curriculum • 16 U.S. medical students in 2009, 37 students

in 2010, reaching 120 admissions/yr in 2013• Goal is to reduce physician shortages in

Louisiana and the Gulf South

AMA Founded in 1847

Shadow of Flexner

Flexner Report Transformed Medical Education in the United States

Th M di l C TThe Medical Care Team